Medical Form [Trans9]
Oct. 10th, 2011 03:27 pmPATIENT MEDICAL HISTORY | ||||
Name: Rachel Berenson | Age: 16 years | Sex: Female | Height: 175 cm/5'9" | Weight: 56kg/125lbs |
[ ] Magical by nature/practices magic. | [ ] Can't have magic used on. | [ ] Contagious (see notes). | ||
HUMAN (homo sapiens) | ||||
Average Lifespan: approx. 78 years | Rate of Maturity: approx. 18 years | Average age of Puberty: approx. 13 years | ||
Normal Diet: [Note on human diet attached] Common Ailments: [Note on common human ailments attached] Specific Notes: 'Morphing' heals any injuries and many ailments. |
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GENERAL HEALTH | ||||
All of the following sense-related questions are to be answered in comparison to an average Homo sapiens. Ask your medical provider for assistance in answering this section. |
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Blood Pressure: [X] Average | [ ] Low | [ ] High | ||||
Vision: [X] Fine | [ ] Near Sighted | [ ] Far Sighted | [ ] Enhanced | ||||
If Enhanced, further explain: |
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Hearing: [ ] Deaf | [ ] Low | [X] Average | [ ] High Range | [ ] Low Range | [ ] Extremely Sensitive | ||||
If necessary, further explain: |
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Smell: [ ] Cannot Smell | [ ] Low | [X] Average | [ ] High | [ ] Extremely Sensitive | ||||
If Extremely Sensitive, further explain: |
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Known Allergies: Crocodile DNA Are there any potential complications with healing processes we should be aware of when treating you?: N/A Do you have a healing factor different from the average for your species? If so, explain how here: Capable of 'morphing' which is evidenced to remove injuries in the process. Some instances of it curing ailments have been noted as well. Have you recently been screened for species, sex, and age specific cancer risks?: No. Special notes on care: N/A Record of Past Injuries: [Complete history attached] Ship Health Records: Injuries have been sustained in battle. Broke hand |
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SEXUAL HEALTH | ||||
Have you ever been sexually active?: No. Are you currently Sexually Active: No. Have you recently been screened for STIs?: No. Species specific sexually related health notes and/or issues: N/A |
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Reproductive Health (skip if N/A) | ||||
Date of Last Menses/Estrus/Equiv (skip if n/a): On ship. Number of pregnancies: N/A Number of pregnancies carried to term: N/A Age of first birth/hatching/etc. (if applicable): N/A Total number of births/hatching/etc.: N/A |
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DRUGS AND MEDICATION | ||||
Are you or should you be on any prescribed medication? If so, list below: No. Have you taken any recreational or non-prescribed drugs or substances in the past? Is so, please list them and their frequency of use below: No. Do you currently take any recreational or non-prescribed drugs or substances? Is so, please list them and their frequency of use below: No. |